Paper Chase 2: Head Trauma in the Anticoagulated Patient

Jason W., M.D. -

CT all head bonks who are on Coumadin or Plavix despite severity or GCS?
And you wonder why the US health care costs skyrocket.
Where I work ( Canada ) , IF they get a CT it would be 6 hours after the head injury ( unless depressed GCS ) to minimize false early negatives but heavy waiting placed on clinical history, exam, what the INR is and ability to safely discharge and follow up. A pertinent question I have is how quickly do symptoms develop in the 1% of patients with delayed subdural needing craniotomy? If this develops over days and the surgery urgent that is one this, if it is over hours and surgery is emergent that is different- especially if you are 3 hours from Neurosurgery as where I work.

Dr. Jason Wale, Comox, BC, Canada

Michael M., M.D. -

I was wondering why reversing these patients (with an initial negative CT) with vitamin K was not addressed. If an atrial fibrillation patient has a stroke risk of 5%/year while not anticoagulated, but a 6% dealyed bleed rate and 1% risk of craniotomy within 24hrs after a repeat CT, wouldn't short term reversal be something to consider?

Amelia R., M.D. -

I have one question, once comment.

Do you all consider aspirin therapy when working about bleeds in the elderly with head bonks? I get a wide variety of opinions on that one.

I just saw a patient who had a subdural one year or so ago. Story: lamp fell on his head. Result: craniotomy one month later after arm suddenly went numb and the ED doc ordered an MRI to evaluate. Found bleed. Age, 63. Meds: ACE, lipid, thyroid and baby ASA. He tells me he was seen at the Lompoc ED.

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